Impact of pulmonary vein variant anatomy and cross-sectional orifice area on freedom from atrial fibrillation recurrence after cryothermal single-shot guided pulmonary vein isolation

Abstract

Background Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). This study aimed to evaluate ablation efficacy and freedom from arrhythmia recurrence using the novel POLARx compared to the Arctic Front Advance Pro (AFA) CB system including the analysis of individual PV characteristics. Methods A total of 687 patients underwent CB-guided ablation for AF. Arrhythmia recurrence was defined as an ECG documented episode of any AF/atrial tachycardia (AT) > 30 s. Anatomical characteristics were assessed using magnetic resonance imaging (MRI). For each PV, the cross-sectional orifice area (CSOA) was determined. Follow-up examinations were scheduled after 3, 6, and 12 months. Results Acute PVI was achieved in all patients. Twelve-month AF-free survival was similar between the groups (POLARx 43/86 (50%) vs. AFA 318/601 (53%), Log-rank (LR) p = 0.346). MRI found a comparable percentage of patients with normal PV anatomy (POLARx 71/86 (83%) vs. AFA 530/601 (85%), p = 0.162). Patients with variant PV characteristics presented with a significantly impaired 12-month AF-free survival (normal PVs 326/585 (56%) vs. variant PVs 27/102 (27%), LR p < 0.001) independent of the applied CB ablation system. PAF patients with AF recurrence presented with significantly larger CSOA of the left-sided PVs and the right superior PVs (LSPV: p < 0.001; LIPV: p < 0.001; RSPV: p < 0.001). In PERS AF, no association between CSOA and ablation outcome was observed. Multivariate analyses identified PERS AF (hazard ratio (HR) 2.504, confidence interval (CI), 1.900–3.299, p < 0.001) and variant PV anatomy (HR 2.124, CI 1.608–2.805, p < 0.001) as independent predictors for AF recurrence. Conclusions Both CB ablation systems are associated with comparable 12-month AF-free survival rates. Variant PV anatomy seems to be predictive for AF recurrence. An association between CSOA and the outcome after CB-guided PVI was demonstrated for PAF.

The individual relationship between atrial fibrillation sources from CARTOFINDER mapping and atrial cardiomyopathy

“…1,4,5 Several studies point out the importance of LGE CMR imaging for the visualization of individual atrial fibrosis prior to the ablation procedure. [4][5][6][7] In our study, LGE CMR revealed an intermediate amount of 21.41% ± 6.32% of LA fibrosis consistent with Utah stages II-III. Importantly, no PERS AF patient was assigned to Utah stage I as all patients had more than 10% fibrosis of the LA.…”

Procedural performance between two cryoballoon systems for ablation of atrial fibrillation depends on pulmonary vein anatomy

“…Recent studies have associated POLARx with shorter time to balloon temperature − 30 °C (T‐30), lower balloon nadir temperatures (NT), and longer balloon thawing time till 0 °C (TT0); however, time to isolation (TTI) was similar to AFAP 5,6 . Furthermore, POLARx appeared to be safe, efficacious, and demonstrated a comparable 1‐year outcome 7–10 . Biophysical parameters such as balloon NT and TT0 have been associated with durability of PVI after CB ablation 11–13 .…”

“…Pulmonary vein (PV) anatomy can affect cooling kinetics and CB ablation outcome 14–17 . A recent study demonstrated an association between cross‐sectional orifice area of the superior PVs and outcome after CB ablation in patients with paroxysmal AF 9 . Normal PV anatomy was associated with a significantly improved outcome for both catheter systems 9 .…”

“…A recent study demonstrated an association between cross‐sectional orifice area of the superior PVs and outcome after CB ablation in patients with paroxysmal AF 9 . Normal PV anatomy was associated with a significantly improved outcome for both catheter systems 9 . We addressed the influence of various PV anatomical characteristics on the cooling kinetics of both cryoablation systems by applying an established PV anatomy scoring system to preprocedural magnetic resonance (MR) angiography data 14 …”

‘United We Stand”: A Rare Case of Non-Incorporation of the Common Pulmonary Vein into Left Atrium

“…Persistence of the SPV presenting as a separate atretic chamber and lacking any connection with atrium has been reported as a very rare condition that requires immediate recognition and surgical intervention [13]. Knowing about the incidence and tracing the origin of these anomalous veins has great clinical relevance as it could be misread as an arteriovenous malformation or could be life threatening if noticed only intraoperatively [14].…”